Moda Select Silver 3500 ($0 Virtual Urgent Care through CirrusMD) - 17933TX0010003 Health Insurance Plan
Moda Health Plan, Inc. health insurance plan with the Plan ID 17933TX0010003. The plan is called Moda Select Silver 3500 ($0 Virtual Urgent Care through CirrusMD).
Based on the data of Health Plan Issuer, this plan has an actuarial value of 70.06% (the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 29.94% of the costs of all covered benefits (according to the Issuer).
| Health Insurance Plan ID | 17933TX0010003 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2025 | ||||||||||||||||||
| State | Texas | ||||||||||||||||||
| Health Insurance Issuer | Moda Health Plan, Inc. | ||||||||||||||||||
| Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
| Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
| Health Insurance Plan Variant | 17933TX0010003-00 | ||||||||||||||||||
| Provider Network(s) | NON-PREFERRED PREFERRED | ||||||||||||||||||
| In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Tue, 03 Dec 2024 06:24 GMT). |
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| Available Variants of the Health Plan | Standard Off Exchange Plan - 17933TX0010003-00 Standard On Exchange Plan - 17933TX0010003-01 Open to Indians below 300% FPL - 17933TX0010003-02 Open to Indians above 300% FPL - 17933TX0010003-03 73% AV Silver Plan - 17933TX0010003-04 |
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| Last Plan Update Date | Thu, 29 Aug 2024 00:00 GMT | ||||||||||||||||||
| Last Import Date | Tue, 03 Dec 2024 06:24 GMT |
Benefits of Moda Select Silver 3500 ($0 Virtual Urgent Care through CirrusMD) Health Insurance Plan, 17933TX0010003-00
| Benefit | Covered | In Network | Out Of Network |
|---|---|---|---|
| Abortion for Which Public Funding is Prohibited
|
NO | ||
| Accidental Dental
For treatment within 12 months of the date of injury to restore teeth to a functional state. |
YES | 35.00% Coinsurance after deductible |
100.00% |
| Acupuncture
|
NO | ||
| Allergy Testing
|
YES | 35.00% Coinsurance after deductible |
100.00% |
| Bariatric Surgery
|
NO | ||
| Basic Dental Care - Adult
|
NO | ||
| Basic Dental Care - Child
|
NO | ||
| Chemotherapy
|
YES | 35.00% Coinsurance after deductible |
100.00% |
| Chiropractic Care
Plan uses the term "spinal manipulation." Up to a combined limit of 35 visits per year, including outpatient rehabilitation and spinal manipulation services. |
YES | $50.00 |
100.00% |
| Cosmetic Surgery
|
NO | ||
| Delivery and All Inpatient Services for Maternity Care
Will cover 48-hour hospital stay for uncomplicated vaginal delivery and 96-hour hospital stay for uncomplicated caesarean section. |
YES | 35.00% Coinsurance after deductible |
100.00% |
| Dental Check-Up for Children
|
NO | ||
| Diabetes Education
|
YES | 35.00% Coinsurance after deductible |
100.00% |
| Dialysis
|
YES | 35.00% Coinsurance after deductible |
100.00% |
| Durable Medical Equipment
|
YES | 35.00% Coinsurance after deductible |
100.00% |
| Emergency Room Services
|
YES | 50.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Emergency Transportation/Ambulance
|
YES | 35.00% Coinsurance after deductible |
35.00% Coinsurance after deductible |
| Eye Glasses for Children
1 pair of glasses per year for members through the end of the month in which they reach age 19. Contact lenses covered in lieu of eyeglasses. |
YES | 0.00% |
100.00% |
| Gender Affirming Care
|
YES | 35.00% Coinsurance after deductible |
100.00% |
| Generic Drugs
Retail up to 30-day supply and mail order up to 90-day supply per prescription. Insulin member cost share maximum of $25 for a 30-day supply. Known as the Select tier in the plan, and it includes generic medications that represent the most cost effective option, as well as certain cost effective brand medications. |
YES | $20.00 |
$20.00 |
| Habilitation Services
Up to a limit of 35 visits per year. The limit does not apply to mental health and substance use disorder. |
YES | $50.00 |
100.00% |
| Hearing Aids
1 hearing aid per impaired ear every 3 years. To restore or correction of impaired speech or hearing loss. |
YES | 35.00% Coinsurance after deductible |
100.00% |
| Home Health Care Services
Limit: 60.0 Visit(s) per Year |
YES | 35.00% Coinsurance after deductible |
100.00% |
| Hospice Services
|
YES | 35.00% Coinsurance after deductible |
100.00% |
| Imaging (CT/PET Scans, MRIs)
|
YES | 35.00% Coinsurance after deductible |
100.00% |
| Infertility Treatment
|
NO | ||
| Infusion Therapy
Some medications may be limited to preferred medication suppliers. |
YES | 35.00% Coinsurance after deductible |
100.00% |
| Inpatient Hospital Services (e.g., Hospital Stay)
All usual hospital services and supplies, including semiprivate room, intensive care, and coronary care units; Prior authorization is required. |
YES | 35.00% Coinsurance after deductible |
100.00% |
| Inpatient Physician and Surgical Services
|
YES | 35.00% Coinsurance after deductible |
100.00% |
| Laboratory Outpatient and Professional Services
|
YES | 35.00% Coinsurance after deductible |
100.00% |
| Long-Term/Custodial Nursing Home Care
|
NO | ||
| Major Dental Care - Adult
|
NO | ||
| Major Dental Care - Child
|
NO | ||
| Mental/Behavioral Health Inpatient Services
|
YES | 35.00% Coinsurance after deductible |
100.00% |
| Mental/Behavioral Health Outpatient Services
In-network: Virtual care visits $15 copay; in-person office visits and intensive outpatient visits $25 copay; other outpatient services 35% after deductible. / For Zero Cost Sharing plans: All outpatient visits $0 copay. / For 87% AV Level Plan CSR In-network: Virtual care visits $10 copay; in-person office visits and intensive outpatient visits $20 copay; other outpatient services 35% after deductible. / For 94% AV Level Plan CSR In-network: Virtual care visits $5 copay; in-person office visits and intensive outpatient visits $10 copay; other outpatient services 35% after deductible. |
YES | $25.00 |
100.00% |
| Non-Preferred Brand Drugs
Retail up to 30-day supply and mail order up to 90-day supply per prescription. Insulin member cost share maximum of $25 for a 30-day supply. Known as the Non-preferred tier in the plan, and these medications do not have significant therapeutic advantage over their preferred alternatives. These products generally have safe and effective options available under the Value, Select and/or Preferred tiers. |
YES | 50.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Nutritional Counseling
For some medical conditions. |
YES | 35.00% Coinsurance after deductible |
100.00% |
| Orthodontia - Adult
|
NO | ||
| Orthodontia - Child
|
NO | ||
| Other Practitioner Office Visit (Nurse, Physician Assistant)
In-network: Virtual care visits $15 copay; in-person visits $25 copay. / For Zero Cost Sharing plans: Virtual care and in-person visits $0 copay. / For 87% AV Level Plan CSR In-network: Virtual care visits $10 copay; in-person visits $20 copay. / For 94% AV Level Plan CSR In-network: Virtual care visits $5 copay; in-person visits $10 copay. |
YES | $25.00 |
100.00% |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
|
YES | 35.00% Coinsurance after deductible |
100.00% |
| Outpatient Rehabilitation Services
Outpatient rehabilitation services have a combined limit of 35 visits per year for rehabilitation and spinal manipulation. The limit does not apply to mental health and substance use disorder. |
YES | $50.00 |
100.00% |
| Outpatient Surgery Physician/Surgical Services
|
YES | 35.00% Coinsurance after deductible |
100.00% |
| Preferred Brand Drugs
Retail up to 30-day supply and mail order up to 90-day supply per prescription. Insulin member cost share maximum of $25 for a 30-day supply. Known as the Preferred tier in the plan, and it includes generic medications that have no more favorable outcomes, from a clinical perspective, than other more cost effective generic medications . |
YES | 40.00% |
40.00% |
| Prenatal and Postnatal Care
|
YES | 35.00% Coinsurance after deductible |
100.00% |
| Preventive Care/Screening/Immunization
7 exams ages 1 to 4 and one per year age 5 and over. See policy for other visit limits. |
YES | 0.00% |
100.00% |
| Primary Care Visit to Treat an Injury or Illness
In-network: Virtual care visits $15 copay; in-person visits $25 copay. / For Zero Cost Sharing plans: Virtual care and in-person visits $0 copay. / For 87% AV Level Plan CSR In-network: Virtual care visits $10 copay; in-person visits $20 copay. / For 94% AV Level Plan CSR In-network: Virtual care visits $5 copay; in-person visits $10 copay. |
YES | $25.00 |
100.00% |
| Private-Duty Nursing
|
NO | ||
| Prosthetic Devices
|
YES | 35.00% Coinsurance after deductible |
100.00% |
| Radiation
|
YES | 35.00% Coinsurance after deductible |
100.00% |
| Reconstructive Surgery
Examples of covered services include: Treatment provided for reconstructive surgery following cancer surgery; Reconstruction of the breast on which mastectomy has been performed. |
YES | 35.00% Coinsurance after deductible |
100.00% |
| Rehabilitative Occupational and Rehabilitative Physical Therapy
Outpatient rehabilitation services have a combined limit of 35 visits per year for rehabilitation and spinal manipulation. The limit does not apply to mental health and substance use disorder. |
YES | $50.00 |
100.00% |
| Rehabilitative Speech Therapy
Outpatient rehabilitation services have a combined limit of 35 visits per year for rehabilitation and spinal manipulation. The limit does not apply to mental health and substance use disorder. |
YES | $50.00 |
100.00% |
| Routine Dental Services (Adult)
|
NO | ||
| Routine Eye Exam (Adult)
1 exam per year |
YES | $10.00 |
100.00% |
| Routine Eye Exam for Children
1 exam per year for members through the end of the month in which they reach age 19. |
YES | $0.00 |
100.00% |
| Routine Foot Care
When required for medical conditions. |
YES | 35.00% Coinsurance after deductible |
100.00% |
| Skilled Nursing Facility
Limit: 25.0 Visit(s) per Year |
YES | 35.00% Coinsurance after deductible |
100.00% |
| Specialist Visit
In-network: Virtual care visits $15 copay; in-person visits $50 copay. / For Zero Cost Sharing plans: Virtual care and in-person visits $0 copay. / For 87% AV Level Plan CSR In-network: Virtual care visits $10 copay; in-person visits $40 copay. / For 94% AV Level Plan CSR In-network: Virtual care visits $5 copay; in-person visits $20 copay. |
YES | $50.00 |
100.00% |
| Specialty Drugs
Up to 30-day supply per prescription at designated specialty pharmacies only. Non-Preferred Specialty tier may have higher cost sharing. |
YES | 40.00% |
100.00% |
| Substance Abuse Disorder Inpatient Services
|
YES | 35.00% Coinsurance after deductible |
100.00% |
| Substance Abuse Disorder Outpatient Services
In-network: Virtual care visits $15 copay; in-person office visits and intensive outpatient visits $25 copay; other outpatient services 35% after deductible. / For Zero Cost Sharing plans: All outpatient visits $0 copay. / For 87% AV Level Plan CSR In-network: Virtual care visits $10 copay; in-person office visits and intensive outpatient visits $20 copay; other outpatient services 35% after deductible. / For 94% AV Level Plan CSR In-network: Virtual care visits $5 copay; in-person office visits and intensive outpatient visits $10 copay; other outpatient services 35% after deductible. |
YES | $25.00 |
100.00% |
| Transplant
Authorized tranplant facility only. Prior authorization is required. |
YES | 35.00% Coinsurance after deductible |
100.00% |
| Treatment for Temporomandibular Joint Disorders
Non-surgical or non-diagnostic services not covered. |
YES | 35.00% Coinsurance after deductible |
100.00% |
| Urgent Care Centers or Facilities
In-network: Virtual care visits $0 copay via CirrusMD; in-person visits $50 copay. / For Zero Cost Sharing plans: Virtual care and in-person visits $0 copay. / For 87% AV Level Plan CSR In-network: Virtual care visits $0 copay via CirrusMD; in-person visits $40 copay. / For 94% AV Level Plan CSR In-network: Virtual care visits $0 copay via CirrusMD; in-person visits $20 copay. |
YES | $50.00 |
100.00% |
| Weight Loss Programs
|
NO | ||
| Well Baby Visits and Care
1 in-hospital newborn visit and 6 additional visits for the first year of life. |
YES | $0.00 |
100.00% |
| X-rays and Diagnostic Imaging
|
YES | 35.00% Coinsurance after deductible |
100.00% |
Moda Select Silver 3500 ($0 Virtual Urgent Care through CirrusMD) Health Insurance Plan Variant 17933TX0010003-00 Attributes
| Plan Attribute | Value |
|---|---|
| Begin Primary Care Cost-Sharing After Number Of Visits | 0 |
| Begin Primary Care Deductible Coinsurance After Number Of Copays | 0 |
| Business Year | 2025 |
| Child-Only Offering | Allows Adult and Child-Only |
| Composite Rating Offered | No |
| CSR Variation Type | Standard Silver Off Exchange Plan |
| Dental Only Plan | No |
| Design Type | Not Applicable |
| Disease Management Programs Offered | Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management, Pregnancy |
| EHB Percent of Total Premium | 0.9990000000000001 |
| First Tier Utilization | 100% |
| Formulary ID | TXF002 |
| Formulary URL | URL |
| HIOS Product ID | 17933TX001 |
| Import Date | 2024-08-29 01:02:15 |
| Limited Cost Sharing Plan Variation - Estimated Advanced Payment | $0.00 |
| Inpatient Copayment Maximum Days | 0 |
| HSA Eligible | No |
| New/Existing Plan | Existing |
| Notice Required for Pregnancy | No |
| Is a Referral Required for Specialist? | No |
| Issuer Actuarial Value | 70.06% |
| Issuer ID | 17933 |
| Issuer Marketplace Marketing Name | Moda Health Plan, Inc. |
| Market Coverage | Individual |
| Medical Drug Deductibles Integrated | Yes |
| Medical Drug Maximum Out of Pocket Integrated | Yes |
| Metal Level | Silver |
| Multiple In Network Tiers | No |
| National Network | No |
| Network ID | TXN001 |
| Out of Country Coverage | Yes |
| Out of Country Coverage Description | Emergency care only |
| Out of Service Area Coverage | Yes |
| Out of Service Area Coverage Description | Emergency care and out-of-area dependent coverage |
| Plan Brochure | URL |
| Plan Effective Date | 2025-01-01 |
| Plan Expiration Date | 2025-12-31 |
| Plan ID (Standard Component ID with Variant) | 17933TX0010003-00 |
| Plan Marketing Name | Moda Select Silver 3500 ($0 Virtual Urgent Care through CirrusMD) |
| Plan Type | EPO |
| Plan Variant Marketing Name | Moda Select Silver 3500 ($0 Virtual Urgent Care through CirrusMD) |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $3,200 |
| SBC Scenario, Having a Baby, Copayment | $10 |
| SBC Scenario, Having a Baby, Deductible | $3,500 |
| SBC Scenario, Having a Baby, Limit | $50 |
| SBC Scenario, Having Diabetes, Coinsurance | $1,700 |
| SBC Scenario, Having Diabetes, Copayment | $300 |
| SBC Scenario, Having Diabetes, Deductible | $400 |
| SBC Scenario, Having Diabetes, Limit | $20 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $200 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $2,300 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | TXS001 |
| Source Name | HIOS |
| Plan ID | 17933TX0010003 |
| State Code | TX |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Group | per group not applicable |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Person | per person not applicable |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Individual | Not Applicable |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Group | per group not applicable |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Person | per person not applicable |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Individual | Not Applicable |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Default Coinsurance | 35.00% |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group | $7000 per group |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person | $3500 per person |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $3,500 |
| Combined Medical and Drug EHB Deductible, Out of Network, Family Per Group | per group not applicable |
| Combined Medical and Drug EHB Deductible, Out of Network, Family Per Person | per person not applicable |
| Combined Medical and Drug EHB Deductible, Out of Network, Individual | Not Applicable |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Group | $17200 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $8600 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $8,600 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Group | per group not applicable |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Person | per person not applicable |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Individual | Not Applicable |
| Unique Plan Design | Yes |
| URL for Enrollment Payment | URL |
| URL for Summary of Benefits & Coverage | URL |
| Wellness Program Offered | No |
Copay & Coinsurance of Moda Select Silver 3500 ($0 Virtual Urgent Care through CirrusMD) Health Insurance Plan, 17933TX0010003
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about Moda Select Silver 3500 ($0 Virtual Urgent Care through CirrusMD), 17933TX0010003 Health Insurance Plan, 17933TX0010003
-
Does Moda Select Silver 3500 ($0 Virtual Urgent Care through CirrusMD) Health Insurance Plan, 17933TX0010003 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (17933TX0010003) Health Insurance Plan, Variant (17933TX0010003-00) offer Disease Management Programs?
Does (17933TX0010003) Health Insurance Plan, Variant (17933TX0010003-00) have Out Of Country Coverage?
Does (17933TX0010003) Health Insurance Plan, Variant (17933TX0010003-00) have Out of Service Area Coverage?
Does (17933TX0010003) Health Insurance Plan, Variant (17933TX0010003-00) offer Disease Management Programs?
Does Moda Select Silver 3500 ($0 Virtual Urgent Care through CirrusMD) Health Insurance Plan, Variant (17933TX0010003-00) offer Disease Management Programs for Asthma?
Does Moda Select Silver 3500 ($0 Virtual Urgent Care through CirrusMD) Health Insurance Plan, Variant (17933TX0010003-00) offer Disease Management Programs for Heart disease?
Does Moda Select Silver 3500 ($0 Virtual Urgent Care through CirrusMD) Health Insurance Plan, Variant (17933TX0010003-00) offer Disease Management Programs for Depression?
Does Moda Select Silver 3500 ($0 Virtual Urgent Care through CirrusMD) Health Insurance Plan, Variant (17933TX0010003-00) offer Disease Management Programs for Diabetes?
Does Moda Select Silver 3500 ($0 Virtual Urgent Care through CirrusMD) Health Insurance Plan, Variant (17933TX0010003-00) offer Disease Management Programs for High blood pressure & high cholesterol?
Does Moda Select Silver 3500 ($0 Virtual Urgent Care through CirrusMD) Health Insurance Plan, Variant (17933TX0010003-00) offer Disease Management Programs for Low back pain?
Does Moda Select Silver 3500 ($0 Virtual Urgent Care through CirrusMD) Health Insurance Plan, Variant (17933TX0010003-00) offer Disease Management Programs for Pregnancy?
Disclaimer: This is based on the import(Date: Tue, 03 Dec 2024 06:24 GMT) of the data from Healthcare Issuers listed by CMS. While we make every effort to ensure that data is accurate, you should assume all results are unvalidated. Source: CMS.gov, HealthPorta HEALTHCARE MRF API